Health inspection·March 17, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 2 of 25 sampled residents (Resident 61, and 81), when: 1. Resident 61 did not have a behavior care plan developed for the use of Seroquel and Zyprexa (both antipsychotic medications, that alter mood and behavior). 2. Resident 81 did not have an accident care plan developed when she hit her chin on her bedrail, and sustained a bruise. These failures had the potential for important medical and emotional services that these residents needed, to go unrecognized and untreated which could lead to negative clinical outcomes. Findings: 1. Resident 61's medical record was reviewed. Resident 61 was admitted on [DATE], with diagnoses that included, liver cancer, bone cancer, bipolar disorder (mood swings ranging from depression lows to manic highs), and anxiety. On 3/14/22 at 11:15 am, during an interview, Resident 61 stated that he was taking Seroquel and Zyprexa because he felt, scared and his mind races. Resident 61's record indicated that their physician had ordered both Seroquel and Zyprexa, upon admission on [DATE]. A review Resident 61's care plans, indicated that no care plans had been developed for his problems of feeling scared, and having racing thoughts. There were no goals or interventions which described the necessary steps required to help Resident 61 to correct these unwanted behaviors. 2. Resident 81's medical record was reviewed. Resident 81 was admitted on [DATE], with diagnoses that included a blood clot in her lung, weight loss, difficulty walking, and a history of falling. On 3/14/22 at 10:30 am, Resident 81 was observed in her bed with a dark purple bruise about the size of a half dollar under her chin. Resident 81 stated that the bruise was from her getting into bed and, somehow I hit my chin on the bedrail. She did not recall the exact date that it happened, but did indicate that she told the staff. A review Resident 81's care plans, indicated that no care plans had been developed for her bruised chin. There were no goals or interventions in place that described the necessary steps required to ensure that her bruise resolved without complications, and to mitigate further accidents. The facility's policy titled, Care Plans, Comprehensive, revised 1/11, was reviewed, and indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs will be developed for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm On 3/16/22 at 9:04 am, during an interview, and concurrent record review, with the Assistant Director of Nursing (ADON) B. ADON B confirmed that Resident 61, and 81, did not have care plans developed for the above problems and, should have when the problems were first identified. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the comprehensive care plan was implemented for one of 25 sampled residents (Resident 6), when the physician orders for use of a topical cream were not followed and wound treatment was noted to have continued after the wounds were healed. Residents Affected - Few This failure resulted in Resident 6 receiving a medicated cream, in error, and inaccuracies in the medical record. Findings: Resident 6's medical record was reviewed. Resident 6 was admitted on [DATE], with diagnoses that included lung disease, diabetes, and muscle weakness. The nurse's progress note dated 3/5/22, indicated that Resident 6 was receiving treatment for a pressure injury. There was a physician's order dated 1/18/22, for mometasone (steroid medication used to relieve itching, redness, and swelling) cream 0.1% to be applied in a thin layer to small scabbed areas on scalp, discontinue when resolved. During a concurrent interview, and record review, on 3/16/22 at 10:15 am, the Treatment Nurse (TN) reported that Resident 6 had been admitted with two pressure injuries (bedsores), and the last one had healed on 2/10/22. After Resident 6 was admitted she complained of itchiness on her scalp. TN said she didn't actually see anything, but the resident complained of itching, so the physician was told and ordered mometasone cream to the area. The TN reported that this area on the scalp was noted to be resolved on 1/29/22. The TN explained that the nurses could do their own assessments, or look in the record to know when she had documented that the wounds had resolved. The wound treatment record for the pressure injury showed treatment ended on 2/10, which was the day it had resolved. Further review, of the record indicated that nurses's progress notes dated; 2/25-2/27/22, 3/4/22, and 3/5/22, from three different nurses, that indicated that Resident 6 was still receiving treatment for the buttock pressure injury, even though treatment had already been discontinued on 2/10/22. A review of the treatment record on 3/15/22, indicated that Resident 6 continued to receive the cream the physician ordered to be applied to the scalp, even though it should have been discontinued when the wound resolved, on 1/29/22. During an interview, on 3/16/22 at 1:20 pm, Resident 6 said she had a sore on her head but it had gone away. Resident 6 also said that she had came in with a couple sores on her buttock, and those have healed. The above information was discussed in an interview, with the Director of Nurses (DON) on 3/16/22 at 1:40 pm. The DON stated that she would follow up, but no additional information was received. During a subsequent interview, on 3/17/22 at 1:20 pm, TN stated that the nurses have been asked to check the event report to make sure treatment was ongoing for wounds, before charting such. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents, and appropriate post fall or post accident care for two of 5 sampled residents (Residents 19 and 81), with a history of falls, when: 1. Resident 19 had five falls within two-months. Neuro (neurological assessments include mental status, motor function, pupillary responses and vital signs) checks were not done according to the facility policy for any of the five falls (all of which were unwitnessed, or the resident hit her head), interventions in the care plan were not implemented during the fall on 1/12/22, post fall injuries sustained on 2/17/22, were not monitored according to the care plan, and the falls care plan was not updated with appropriate interventions, relating to the cause of the falls, which occurred on 1/18/22, 2/17/22, and 3/10/22. This had the potential to result in more falls with major injuries. 2. The facility also failed to ensure the bathroom hot water temperature was safe for all residents in the facility. This had the potential to result in burns to the residents. Findings: The facility's policy titled, Falls and Fall Risk, Managing, dated 3/18, was reviewed, and indicated that a fall was defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless, there is evidence suggesting otherwise, where a resident is found on the floor, a fall is considered to have occurred. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approaches remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. The facility's undated policy titled, Falls, was reviewed, and indicated that a following a fall a complete head to toe assessment will be completed, neuro checks (if applicable) every 15-minutes for four times, every 30-minutes for two times, every one hour for two times, every two hours for two times, every four hours for four times, every eight hours for six times, for a total of 72 hours. Staff will create a fall care plan. 1. Resident 19's medical record was reviewed. Resident 19 was admitted on [DATE], with diagnoses that included lung disease, ataxia (impaired balance or coordination due to damage to the brain, nerves, or muscles), anxiety disorder, and high blood pressure. During a two month period from 1/12/22 through 3/10/22, Resident 19 fell five times. Resident 19 fell on 1/12/22, 1/16/22, 1/18/22, 2/17/22, and 3/10/22. During a concurrent interview, and record review, on 3/17/22 at 10 am, Assistant Director of Nurses (ADON) A reported that after a resident has fallen, the physician and Responsible Party are notified, neuro checks are complete if there was a head injury, or with an unwitnessed fall, vital signs, full assessment, an Event report is done, care plans updated, alert charting for 72-hours, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Interdisciplinary Team (IDT) who meets Monday through Friday would discuss any event from the prior day. Level of Harm - Minimal harm or potential for actual harm The five falls Resident 19 had were then reviewed with ADON A. Residents Affected - Some On 1/12/22 at 12:15 am, Resident 19 was found sitting beside the bed reaching for her call light and fell out of bed. In the Event Report a neuro check was done, and was within normal limits, and the cause was noted to be, call light not within reach. ADON A confirmed that a fall care plan had been started upon admission on [DATE], and included, keeping the call light within reach. On 1/16/22 at 12:16 am, Resident 19 was found sitting on the floor beside her bed, a neuro check was included in the Event Report and was within normal limits. ADON A confirmed that a landing pad (which is the same as a fall mat) was added to Resident 19's fall care plan. On 1/18/22 at 6:52 am, Resident 19 fell out of bed while a Certified Nursing Assistant (CNA) was changing her brief, and hit her head. The initial neuro check was included in the Event Report. ADON A said that the initial neuro checks were in the Event Report, and subsequent ones were hand written per their falls policy. The care plan was updated on 1/19/22, and the new intervention added was to move Resident 19 to her current room, which was closer to the nurse's station. The Event Report listed the cause as the resident rolling off the bed as the CNA changed her, so the new intervention had nothing to do with the cause of this fall. On 2/17/22 at 10:43 pm, Resident 19 rolled out of bed and was noted to sustain injuries to her face, and right forehead. ADON A confirmed the type of injuries were not included in the nurse's progress note, and the neuro checks were not included in the Event Report. The care plan was updated to include a fall mat to both sides of the bed. ADON A said the resident had a history of rolling out of bed, and had spasticity due to her medical diagnoses. She was asked about the fall mats and why they were not placed on both sides of the bed, for safety, when the resident rolled out on 1/16, given the resident's history of rolling out of bed, instead of waiting until she rolled out again on 2/17/22, and sustained injuries. ADON A said she was unable to tell which side of the bed the resident had rolled out of during any of the falls, and she did not know which side of the bed the first fall mat was placed. ADON A stated, We can't use all our interventions at one time, otherwise we won't have anything new to try the next time she falls. The resident's next fall on 3/10/22 at 7:15 pm, was then discussed with ADON A. There was a Telehealth note from a physician that indicated the resident was found on her left side and had two new bumps on her head, and expressed head pain and indicated left elbow and right hip pain. The Event Report included a neuro check. The care plan was then updated for, TV stand to be strapped to wall. ADON A said for the 3/10/22 fall, the resident crawled out of bed, grabbed the TV, and pulled it over on her and that was the reason for the new intervention of strapping the TV to the wall. She said there was an internal report that was not part of the resident's medical record regarding the TV. ADON A said she was unable to tell if the MD who evaluated the resident had been told the TV fell on her or not, as the note only says resident was found lying on her left side. During an interview, on 3/17/22 at 10:40 am, the Medical Records Director (MRD) provided a copy of a late entry note recorded in the chart on 3/17/22 at 3:55 am, and 3:57 am (six days after the incident, and after the survey began) that indicated resident's neuro signs were normal on 3/12/22 at 9:52 pm, and 3/13/22 at 7:56 pm. The MRD said there were no other neuro checks in the electronic record for this fall, and no paper copy of neuro checks for this fall or any other of the other falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview, on 3/17/22 at 11:05 am, the Administrator said the internal document had been destroyed but no TV had fallen on this resident. He said someone came up with an intervention to strap the TV stand to the wall just because there was a possibility that it could happen, but it did not happen. 2. The facility's undated policy titled, Physical Environment and Accommodations Policy, was reviewed, and indicated that all faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F (41 degrees C) and not more than 120 degrees F (49 degrees C). On 3/14/22 at 9:35 am, room [ROOM NUMBER], with Resident 98 was observed to be alert, had a walker and was walking independently. On 3/14/22 at 10:09 am, the hot water temperature was check in the bathroom for Rooms 2 &4 (resident in these two rooms shared a bathroom), and 6. Both bathroom hot water temperatures were 123.8 degrees F. The Administrator was immediately notified about this. He agreed it was too hot, and said he would talk to maintenance right away. On 3/14/22 at 11:59 am, the hot water temperature was rechecked in room [ROOM NUMBER], at the same time as Maintenance Staff (MS) and both thermometers indicated the same temperature of 119.5 degrees F. On 3/15/22 at 2:50 pm, the hot water temperature was taken in the bathroom shared by the residents in rooms [ROOM NUMBERS], and it was 122 degrees F. The Administrator was immediately notified. During an interview, on 3/16/22 at 2:30 pm, the Plant Supervisor, Maintenance (PSM) provided a copy of bathroom hot water temperatures taken for that day, and all were less than 120 degrees F. He said the plumber checked their system today, and they have a bad circulation pump. PSM said if it couldn't be fixed they would get a new one as soon as possible. The Centers for Medicare and Medicaid Services (CMS) included the below information in its interpretive guidelines for this regulation. Table 1. Time and Temperature Relationship to Serious Burns Water Time Required for a 3rd Degree Temperature Burn to Occur ___________________________________________ 155°F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 68°C Level of Harm - Minimal harm or potential for actual harm 1 sec 148°F Residents Affected - Some 64°C 2 sec 140°F 60°C 5 sec 133°F 56°C 15 sec 127°F 52°C 1 min 124°F 51°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing (see Note) ___________________________________________ NOTE: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Burns can occur even at water temperatures below those identified in the table, Level of Harm - Minimal harm or potential for actual harm depending on an individual's condition and the length of exposure. Residents Affected - Some Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows. *First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. *Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. *Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 1 of 5 sampled resident's medication regimen was free from unnecessary drugs when Resident 61 was given Seroquel (an antipsychotic drug that alters mood and behavior) without monitoring the correct indication for use. This had the potential for Resident 61, and his physician to receive incorrect information regarding the effectiveness of the drug and negatively impact Resident 61's psychosocial and emotional well-being. Findings: Resident 61's medical record was reviewed. Resident 61 was admitted on [DATE], with diagnoses that included, chronic respiratory failure, high blood pressure, liver cancer, bone cancer, bipolar disorder (mood swings ranging from depression lows to manic highs), depression, panic disorder (anxiety) and weight loss. On 3/14/22 at 11:15 am, an observation, and interview, was conducted with Resident 61. He was in his room sitting in a chair and waiting for lunch. He was alert and appropriate with conversation. Resident 61 stated that he was aware that he was taking Seroquel because he felt people were out to get him and he was scared. Resident 61's Physician's Order's dated 2/16/22 to 3/16/22, indicated that Seroquel 100 milligrams (mg) was ordered on 2/17/22, for insomnia (inability to fall asleep). Resident 61, and his daughter signed an informed consent on 2/16/22, indicating that they understood that Seroquel was ordered to help with Insomnia. Resident 61's hours of sleep were monitored. On 2/23/22, Resident 61's medication regimen review (MRR, a review of medications by a Pharmacist) indicated that Seroquel was not recommended or appropriate for Insomnia. Resident 61's physician responded on 2/27/22, and documented, Not for Insomnia, for Paranoia. On 2/27/22, the Physician's Order was changed to,Seroquel 100 mg for Paranoia, however, the behavior monitor was not changed, and Resident 61 continued to be monitored for Insomnia. On 3/16/22 at 9:04 am, an interview, and concurrent record review, was conducted with the Assistant Director of Nursing (ADON) B. ADON B confirmed that Resident 61 was still being monitored for Insomnia, and not Paranoia, as his physician directed and that was not the correct indication for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to provide safe storage, and labeling of medications and medical supplies when: 1. A mislabeled blister pack (a package that is pre-filled with medication by a pharmacy) for a pain medication called tramadol (also known as Ultram, a medication to relieve pain)was not consistent with current doctor's order in one out of four sampled residents (Resident 51). 2. Expired medication, and blood test supplies were stored in the active storage areas in one of two medication rooms. This failure resulted in the potential for unsafe medication use, and inaccurate lab test results in the facility which could lead to negative clinical outcomes. Findings: 1. During a medication pass observation with Licensed Nurse (LN C), on 3/15/22 at 7:48 am, LN C administered Ultram 50 milligrams (mg) to Resident 51. The label on the blister pack read, Tramadol HCL Tab 50 mg [generic for Ultram] take 1 tablet by mouth every 4-hours routine, and 1 tablet twice daily as needed. The Ultram medication label indicated the blister pack had been filled on 3/22. Resident 51's medical record was reviewed. Resident 51's record included three orders for Ultram that indicated: 1. Ultram (tramadol) 50 mg one tablet, once a day at 1400 (2:00 pm), dated 10/06/21. 2. Ultram (tramadol) 50 mg one tablet, every four hours, dated 10/11/20. 3. Ultram (tramadol) 50 mg one tablet, at 2200 (bedtime) dated 3/21/21. There was no order for Ultram to be given as needed. During a concurrent record review, and interview, on 3/16/22, at 2:50 pm with RPH-1 (the facility's pharmacist), RPH-1 reviewed the physician order's and confirmed that the current Ultram order was not consistent with medication label. RPH-1 stated that there was an old Ultram order from October 2021, that matched the label currently being placed on the Ultram blister pack. RPH-1 stated the order from October 2021, was to give Ultram 50 mg every four hours, and two times as needed. RPH-1 confirmed that the label on the Ultram blister pack did not match the current orders, and stated that the label issue must be on our end, and will need to be fixed. During an interview with LN C on 3/16/22 at 3 pm, LN C confirmed the current orders for Ultram, and the label for the Ultram blister pack were incorrect. LN C stated that when the order is changed, a sticker is placed on the blister pack indicating a change of order had occurred, and that when the medication needed to be reordered, the nurse should call the pharmacy to have the label changed. LN C placed a change of order sticker on the Ultram blister pack during interview, and confirmed that the sticker was not present prior. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak River Rehab 3300 Franklin Street Anderson, CA 96007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview, with the Director of Nursing (DON) on 3/16/22, at 5:10 pm, the DON confirmed that a change of order sticker should be placed on the blister pack when a medication order has been changed. The facility's undated policy titled, Storage of medication, was reviewed, and indicated that all medications with incorrect labels, shall be returned to the pharmacy for proper labeling. Residents Affected - Few 2. During a tour of the medication room located at Nurse's Station Two, on 3/15/22, at 8:46 am, accompanied by LN D, the following expired products were observed stored in the active storage areas: 1. One bottle of UTI-STAT (a medical food for urinary tract health), which had expired on 3/11/22. 2. Nine lavender laboratory tubes (used to collect blood samples for laboratory testing) had expired on 2/22. 3. Four sets of culture laboratory bottles (used to determine if there is an infection in a person's blood stream) had expired 2/28/22. During an interview, on 3/15/2022 at 4 pm, with the Director of Nursing (DON), the DON stated that the responsibility of checking for expired medications and supplies fell upon the central supply staff, the Assistant Director of Nursing (ADON), and the night shift nurses, and is to be performed every 24- hours. The facility's undated policy titled, Storage of medications, was reviewed, and indicated that nursing staff shall be responsible for maintaining medication storage, and the facility shall not use discontinued, outdated, or deteriorated drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555147 If continuation sheet Page 12 of 12